Basic Information
Provider Information | |||||||||
NPI: | 1932194792 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KLUTTS | ||||||||
FirstName: | JIMMY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2220 W IOWA AVE | ||||||||
Address2: |   | ||||||||
City: | CHICKASHA | ||||||||
State: | OK | ||||||||
PostalCode: | 730182738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057792113 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2220 W IOWA AVE | ||||||||
Address2: |   | ||||||||
City: | CHICKASHA | ||||||||
State: | OK | ||||||||
PostalCode: | 730182738 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052242300 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0062493 | OK | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 7751127 | 01 | OK | AETNA | OTHER | 4447005008-001 | 01 | OK | BCBS | OTHER |